Closure of an Intermediate Care Unit

Closure of an Intermediate Care UnitThe high cost of providing critical care has provoked a variety of “utilization strategies” within hospitals to optimize use of these scarce resources. The relative scarcity of critical care resources and limited access to them is a result of both increasing demand and restrained supply. One strategy that many hospitals have adopted is the provision of “graded” levels of care in intermediate care units to apportion nursing time and monitoring facilities for specific patient needs. This strategy has been proposed as a cost-effective alternative to critical care unit (CCU) admission, particularly for low-risk patients admitted for monitoring.
Most reports that evaluate the impact of an intermediate level of care on the use of CCU resources do so after the opening of an intermediate care area (ICA). Few, if any, studies have evaluated the impact of closing an ICA on the utilization of a multidisciplinary critical care facility that services both medical and surgical patients. The decision to admit patients to the CCU for monitoring alone is controversial and some investigators have suggested that many of these patients could be safely cared for in an ICA.
A recent budgetary crisis in our adult, tertiary care referral hospital resulted in a decision to close an intermediate care unit that had served as a “step-down” facility as well as a “low-risk” monitoring unit. Our critical care audit system permitted retrospective analysis of the interaction of the structure and organization of hospital facilities with utilization of a multidisciplinary medical-surgical CCU.
This study was conducted in St. Michaels Hospital, an adult, tertiary care referral center affiliated with the University of Toronto. All medical and surgical specialties were available in the hospital. The medical/surgical CCU was a multidisciplinary unit, supervised and staffed by a team of critical care physicians with residents available in the unit 24 h/d. The nursing managers provided one nurse per patient during the time periods studied. Indications for admission to the medical-surgical CCU included the requirement for mechanical ventilatory support, critical care nursing, and/or invasive hemodynamic monitoring not available in other areas of the hospital. With the exception of postoperative cardiac and neurosurgical patients and posttrauma patients who were admitted to other specialized units, all patients requiring critical care were admitted to the CCU during the study period. Utilization was assessed using an ongoing CCU data collection system during two 9-month time periods separated by a 9-month transition period. During the first 9-month period, October 1, 1989 to June 30, 1990 (pre-ICA closure), the 7-bed medical-surgical CCU operated independent of a separate 6-bed ICA that admitted both medical and surgical patients not requiring invasive hemodynamic monitoring or mechanical ventilatory support. The medical supervision of the ICA was independent of the CCU staff. Patients requiring intensive nursing care (two nurses, one patient) but not continuous hemodynamic monitoring or respiratory support were admitted to the ICA facility based on medical and nursing needs. A 9-month interval between pre- and post-ICA closure data collection allowed an adjustment period in admission/discharge policies after closure of the ICA and redistribution of hospital beds and staff. During the second 9-month data collection, April 1, 1991 to January 5,1992 (post-ICA closure), an expanded (9-bed) medical-surgical CCU operated without an ICA. During this post-ICA closure period, all patients requiring more intensive nursing and medical care than available on the regular wards were admitted to the CCU.

This entry was posted in Care and tagged care resources, ccu patients, critical care, intermediate care.